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PAP231

Recommended Preventive Benefits

Provider Administrative Policy

SectionClaims Submission

Policy DateJuly 2007

Status/DateRevised/September 2014

Provider Type(s)
Physician

Disclaimer

Our provider administrative policies contain information regarding claims submission, reimbursement, and other information in order to achieve an efficient relationship with our providers. These policies are not an authorization or explanation of benefits. Blue Cross of Idaho retains the right to add to, delete from and otherwise modify this policy in accordance with our provider contracts

The Departments of Health and Human Services (HHS) issued interim final regulations requiring new plans and insurers to cover certain preventive services without any cost-sharing for the member when delivered by contracting or participating (in-network) providers. The interim final regulations do not apply to grandfathered plans. Grandfathered plans are exempt from certain provisions of this law.

Prior to a plan or policy renewal, or if a self-insured plan remains grandfathered, the current wellness/preventive member benefits apply.

Upon plan or policy renewal: Members can receive the recommended preventive services without member cost-sharing when delivered by an in-network provider. Both the Patient Protection and Affordable Care Act's (PPACA) general requirement and the new rules link to three government agencies that publish recommendations and guidelines for preventive care and require plans to provide in-network coverage for:

Evidence-based items or services rated A or B in the United States Preventive Services Task Force recommendations

Immunizations for routine use in children, adolescents, and adults that are recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control (CDC) and Prevention (See PAP505)

Another portion of the medical benefit plan may cover services not covered under the preventive care benefit.

Preventive care benefits do not cover the cost of drugs, medications, vitamins or supplements recommended or prescribed for preventive measures. Examples include, but are not limited to:

Aspirin for any indication, including but not limited to, aspirin for prevention of cardiovascular disease.

Chemoprevention for any indication, including but not limited to, chemoprevention for breast cancer.

Supplements, including but not limited to: oral fluoride supplementation, and folic acid supplementation.

Blue Cross of Idaho will identify services by the diagnosis code.

Modifier 33 Preventive Service; When the primary purpose of the service is the delivery of an evidence based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be identified by adding 33 to the procedure. For separately reported services specifically identified as preventive, the modifier should not be used.

While modifier 33 may be reported, Blue Cross of Idaho is not currently recognizing it when determining whether preventive care benefits would apply.